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So your probably sitting there with shaking hands reading this terrifying document from the Department of Justice demanding every single billing record, patient file, and email your practice has generated in the last six years. Maybe a whistleblower complaint triggered it. Maybe Medicare’s data analytics flagged your billing patterns. Or maybe your just unlucky and got swept up in there latest healthcare fraud takedown. Look, we get it. Your ABSOLUTELY TERRIFIED. And you should be! Because healthcare fraud violations under the False Claims Act carry penalties up to THREE TIMES your alleged damages plus $11,000 per claim!
Let me explain exactly what your dealing with here. A Civil Investigative Demand is the government’s nuclear weapon for investigating healthcare fraud before they actualy file charges. Under the False Claims Act, the Attorney General can issue CIDs demanding documents, written answers to questions (called interrogatories), and even sworn testimony – all without needing a judge’s approval.
Your probably got this CID because someone – maybe a disgruntled employee, a competitor, or even a patient – filed a qui tam whistleblower lawsuit against you. These cases are filed under seal, meaning you don’t even know about them while the government investigates. We’ve seen practices get CIDs two years after the whistleblower filed there complaint!
The really scary part? The government doesn’t need to prove you intentionaly committed fraud. Under the FCA, “knowing” includes reckless disregard or deliberate ignorance. So that billing system you never fully understood? Those coding decisions your staff made? That consultant who said your arrangement was “probably fine”? None of that protects you. If there’s a violation, your liable for MASSIVE penalties.
Want to know the nightmare scenario? Let us paint you a picture that’ll keep you up all night. The False Claims Act allows penalties of up to three times the government’s losses plus $11,000 per claim. But wait – it gets worse. Each individual service, each line item on a claim, each date of service counts as a seperate claim.
We had a small practice that billed 50 patients a day for three years with incorrect codes. Do the math: 50 claims x 250 working days x 3 years = 37,500 individual false claims. At $11,000 minimum per claim, that’s $412 MILLION in penalties before we even talk about treble damages! The practice had annual revenue of $2 million. They were completley destroyed.
And that’s just civil penalties. Healthcare fraud can also trigger criminal charges with up to 5 years in federal prison per count. Plus exclusion from Medicare and Medicaid – basicaly a death sentence for any healthcare provider. We’ve seen doctors lose there licenses, there homes, and there freedom over billing mistakes they didn’t even know were wrong.
The scope of healthcare fraud CIDs is absolutley staggering. There gonna demand everything: Complete patient files including all medical records, billing records for every single claim submitted, correspondence with Medicare/Medicaid and private insurers, emails between providers and staff about billing, contracts with referring physicians, marketing materials and patient communications, financial records showing all payments received, compliance policies and training materials.
But here’s what really pisses us off – they want “all documents relating to” these topics. That’s intentionaly vague so they can claim you withheld documents if you miss anything. We’ve seen DOJ claim obstruction because a practice didn’t produce text messages between doctors about patient care. Its a complete fishing expedition designed to find ANYTHING they can use against you.
The interrogatories are even worse. They’ll ask questions like “Identify all instances where services were billed but not rendered” – basicaly asking you to confess to fraud! Or “Describe all financial relationships with referring physicians” – trying to trap you into Anti-Kickback or Stark Law violations.
NO! Absolutley not! This is the worst mistake you can make. Ignoring a healthcare fraud CID is like ignoring a ticking bomb in your office. Here’s what happens if your stupid enough to ignore it:
DOJ will immediately file a motion to compel in federal court. You’ll be held in contempt and face additional penalties. They’ll assume your hiding massive fraud and expand there investigation. Your case will be flagged as “uncooperative” guaranteeing maximum penalties. Criminal charges become much more likely.
We had a physician who thought he could just ignore a CID because he was “too busy seeing patients.” Six months later, FBI agents raided his practice, seized all his computers, froze his bank accounts, and arrested him for obstruction. His practice collapsed within a week. Don’t be that guy.
Your probably wondering “Why me? What did I do?” Let us tell you the most common triggers for healthcare fraud CIDs, and some of these will shock you.
Whistleblower complaints are huge – especialy from fired employees who know exactly what to report to maximize there reward (they get up to 30% of what the government recovers!). Data analytics is another big one – Medicare uses sophisticated algorithms to identify “outliers” in billing patterns. If your billing looks different from your peers, your flagged.
Referral patterns trigger investigations too. If you refer alot to certain specialists or order more tests than average, they assume kickbacks are involved. Patient complaints to Medicare can trigger full investigations. Even random audits can escalate to fraud investigations if they find any issues. And here’s the really unfair part – being associated with another provider under investigation can get you a CID even if you did nothing wrong!
Technically yes, but there’s some wiggle room if you know what your doing. The CID probably demands an impossibly broad scope of documents. We can negotiate to narrow the scope, but you have to be strategic about it.
You can’t just refuse to produce documents because it’s burdensome – DOJ doesn’t care if it takes you 1,000 hours to comply. But we can argue certain requests are vague, seek clarification on ambiguous terms, propose reasonable limitations on date ranges, and negotiate phased production schedules.
The key is showing good faith while protecting your interests. We know exactly how far we can push back without triggering DOJ’s anger. Push too hard and they’ll assume your hiding something. Don’t push at all and you’ll bury yourself producing unnecessary documents that create more problems.
This is where things get really tricky with healthcare fraud CIDs. Yes, attorney-client privilege exists, but it’s much narrower than you think. Communications with your lawyer about legal advice are protected. But here’s what’s NOT protected:
Business advice from attorneys (even if there also lawyers), documents created in the ordinary course of business, communications with non-attorneys (even if lawyers were copied), underlying facts (the privilege covers communications, not facts), anything disclosed to third parties.
We’ve seen practices accidentally waive privilege by producing emails where lawyers gave business advice mixed with legal advice. Once you waive privilege on a topic, it’s gone for ALL communications on that topic. That’s why you need experienced healthcare fraud attorneys managing your document production – one mistake can destroy your entire defense.
Usualy 30 days, but that’s basicaly impossible for the scope of documents they demand. We immediately request extensions – DOJ usualy grants them if you show your working in good faith. But here’s the thing – every day you delay costs money and makes you look worse.
The timeline pressure is intentional. They want you to panic, make mistakes, and produce documents without proper review. We’ve seen practices hand over privileged documents, inadvertently confess to violations, and create new problems because they rushed there response.
The real timeline looks like this: Day 1-7: Implement legal hold and retain counsel, Day 8-21: Collect and review documents, Day 22-28: Prepare privilege log and productions, Day 29-30: Finalize response and negotiate with DOJ. But that assumes everything goes perfectly, which it never does.
This is the million-dollar question, literaly. Complete cooperation might get you leniency, but it also means handing DOJ the rope to hang you with. Fighting everything makes you look guilty and guarantees they’ll throw the book at you. The answer is strategic selective cooperation.
We cooperate on clear, reasonable requests while challenging overbroad or improper demands. We produce documents that help your case while protecting harmful materials through proper privilege claims. We answer interrogatories carefully without making admissions. Most importantly, we control the narrative by explaining context DOJ might misunderstand.
The government charged 324 defendants last year alone in healthcare fraud cases. They’ve recovered billions in settlements. But here’s the secret – most cases settle because providers panic and cooperate too much, giving DOJ everything they need to extract massive penalties.
Let us tell you exactly what DOJ is looking for in your records, because knowing there playbook helps us defend you. The most common allegations include:
Upcoding – billing for more expensive services than provided. We see this constantly with evaluation and management codes. Unbundling – seperating services that should be billed together. Its an honest mistake that DOJ treats as intentional fraud. Medical necessity issues – performing services that weren’t needed. But who decides what’s “necessary”? Often it’s a government doctor who’s never seen your patient!
Kickback schemes are huge – any financial relationship with referral sources gets scrutinized. Even buying lunch for a referring physician can be twisted into a kickback. Stark Law violations for physician self-referrals are strict liability – meaning even technical violations with no fraudulent intent carry massive penalties. Documentation issues where services were provided but not properly documented – DOJ’s position is “if it wasn’t documented, it didn’t happen.”
YES! And it happens more than you think. Healthcare fraud CIDs often run parallel to criminal investigations. The same conduct can trigger both civil and criminal liability. We’ve seen routine billing disputes turn into federal indictments.
Criminal healthcare fraud under 18 U.S.C. § 1347 carries up to 10 years in prison per count. If someone was injured, it jumps to 20 years. Health care fraud resulting in death? Life in prison. And these aren’t empty threats – DOJ’s Healthcare Fraud Strike Force has criminaly charged thousands of providers.
The transition from civil to criminal usually happens when DOJ finds evidence of intentional fraud, false statements to investigators, obstruction like destroying documents, or patterns showing deliberate schemes. We’ve defended doctors who went from respected physicians to federal inmates because they didn’t take CIDs seriously enough.
Look, we’re not your typical white-collar defense firm that treats healthcare fraud like any other financial crime. We specialize in defending healthcare providers against these devastating investigations. We know the False Claims Act inside and out. We understand medical billing, coding, and documentation requirements. We speak the language of healthcare and can explain why billing decisions that look suspicious to DOJ are actualy legitimate medical judgments.
More importantly, we know how to negotiate with DOJ’s Healthcare Fraud Unit. We know which prosecutors are reasonable and which ones are looking to make examples. We know when to cooperate and when to fight. We’ve taken these cases to trial and won when other firms would have folded.
Most firms will tell you to just cooperate fully and hope for mercy. That’s exacty what DOJ wants – an easy victory with maximum penalties. We fight back strategically, challenging there interpretations, questioning there evidence, and forcing them to prove every element of there case.
After you respond to the CID, DOJ will spend months reviewing your production. They’ll follow up with more demands. They might subpoena your employees for depositions. Eventualy, they’ll make a decision: decline prosecution (rare but possible), pursue civil settlement (most common), or file civil and/or criminal charges (worst case).
If settlement negotiations begin, expect lowball demands for millions in damages plus corporate integrity agreements that handcuff your practice for years. Without experienced counsel, you’ll accept whatever they offer because your terrified. We know how to negotiate these settlements down to manageable amounts while preserving your ability to practice.
Call us RIGHT NOW at 212-300-5196
Every hour matters when facing healthcare fraud allegations!
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Don’t wait another day! The government has unlimited resources and teams of attorneys building there case against you right now. Your medical license, your practice, your freedom – everything is on the line. We’ve helped hundreds of healthcare providers navigate these investigations and come out the other side. But we can’t help if you wait too long.
Remember – one wrong move responding to a healthcare fraud CID can mean the difference between a manageable settlement and losing everything you’ve worked for. The stakes are too high to handle this yourself. Call us NOW before its too late!
Very diligent, organized associates; got my case dismissed. Hard working attorneys who can put up with your anxiousness. I was accused of robbing a gemstone dealer. Definitely A law group that lays out all possible options and best alternative routes. Recommended for sure.
- ROBIN, GUN CHARGES ROBIN
NJ CRIMINAL DEFENSE ATTORNEYS